Welcome! Blood, guts, trauma, surgery, and life saving intervention keep us on the adrenaline roller coaster of the ER. Of course, it's not always positive. The ER can be an emotionally taxing and sometimes heartbreaking workplace, and this blog serves as an outlet for the stress of making life and death decisions each and every day.

Thursday, July 18, 2013

A client and his adult son arrived last night to have their kitty evaluated after a cat fight. Dad let my staff know right away that his son had some mental illness difficulties and would be mostly outside during the evaluation for personal reasons.

The cat, Misty, had two bite wounds on the right thigh and was limping on the right hind limb, but was otherwise very stable. I discussed the finding of the bite wound and recommended minimal wound care. We presented an estimate for wound treatment, antibiotics, pain medicine and an e-collar to prevent Misty from chewing or licking at the area.

Immediately upon reviewing the estimate, the client became irate.

"YOU HAVE UNETHICAL BUSINESS PRACTICES!" he screamed at my receptionist. "My son called three times and was told the entire visit would cost $80, and that's the only reason we're here! Now you're telling me that $80 only covers the exam and consultation?! We never would have come in! This is ridiculous!"

The receptionist tried to de-escalate the situation. She knew that our exam and emergency consultation fee was indeed $80, but that none of our staff would imply this covers all care, nor would they give specific over the phone estimates. It's impossible to know what the situation is for each pet without evaluating the problem in person. She excused herself and found the staff member who had taken that call.

As we suspected, the staff member who did take the call had told the caller that our EXAM fee was $80, and from there we would provide a written estimate for any testing, treatment or medications. The caller continued to demand to know exactly how much the bill would be - WE CAN'T KNOW THIS WITHOUT SEEING YOUR PET. So the staff member told him it could be "hundreds to thousands, there's just no way to know over the phone."

Armed with this information, I stepped into the exam room to chat with the angry client.

"Your staff member tricked my son," he yelled. "You told him it would be $80 for everything, and then we get here and that's just the exam fee. You should tell your customers over the phone what they're going to spend. Otherwise you're just giving us the bait and switch."

I tried to reason with the angry man; explaining that first of all, he was NOT told it would be $80 for everything, that we cannot give specific estimates over the phone because we have no way of evaluating how serious or not a problem is without seeing it in the hospital. Nothing would satisfy the angry fellow, and he continued to yell at me. I offered to remove treatments from the plan, and let him know that he was welcome to decline any services he desired.

"MY SON IS NOT A LIAR. YOUR STAFF MEMBER DID NOT TELL HIM THAT. YOU ARE UNETHICAL BUSINESS PEOPLE!"

He stormed out of the room and approved only minimal care.

At the time of checkout, the man's demeanor had changed.

Suddenly, he apologized for his abhorrent behavior. His son had finally admitted that he WAS told the exam only was $80, and then lied to his dad so that he'd bring the cat in to our clinic.

Tuesday, May 7, 2013

On a spring Saturday shift at the ER, I met a lovely family and their 7 year old German Shepard named Reggie. Reggie had been diagnosed as an epileptic at the young age of 2 years old, but had done incredibly well over his lifetime with proper medications and monitoring. Unfortunately, in the few hours before his arrival to my emergency room, he had experienced 20-30 seizures in rapid succession.

Reggie was admitted to the hospital for medications, monitoring and testing. Additional anti-seizure medications were added to his therapy, and gradually, his seizures abated.

When Monday morning arrived, Reggie's family decided it was time to head back to their primary care veterinarian - a very common occurrence in our world. We stabilize pets in the emergency, and then send them back to their veterinarian for ongoing care.

Later that day, after the general practice had closed, lab testing returned for Reggie. I called his owner to give the results and check on him.

"Reggie didn't have any seizures today," the client reported. "He's there right now."

"Okay," I said. "I hope he feels better soon."

The client seemed nervous, and concerned. "There's someone in their clinic all night, right?" she asked. "They have overnight staff, don't they?"

Our emergency room serves a large part of our community - so primary / daytime veterinarians don't have to be on call at night. It's hard enough to work all night (just ask me!) but it'd be impossible to work all night and the next day, too. For this reason, almost no other clinics in town have overnight techs, and none of the clinics have doctors scheduled on duty overnight. Sometimes they make exceptions, but the vast majority of clinics transfer any unstable patient to us for monitoring overnight.

"I don't know what their staffing schedule is," I replied. "You should ask them about that tomorrow. Sometimes clinics will have a tech stay late, but there's no way for me to know."

The client thanked me for my help, and hung up. I thought that'd be the last I heard from her - but about 45 minutes later we received another panicked phone call. She had just driven past the clinic, looked in the windows and noticed there was no cars in the parking lot, nobody in the building and she knew her dog was in there, unobserved. Reggie could be having any number of seizures, or stuck in constant seizure that won't end, and eventually will lead to death (called status epilepticus) and nobody would be able to help him. The client was in tears, hysterical and upset that nobody had told her he would be alone all night - otherwise she would have just brought him back to our ER or taken him home, where at least someone would know if he was having a seizure.

I couldn't blame her for being upset. Of course, I have no idea if she was told there was nobody in the clinic and chose to ignore it - it wouldn't be the first time a client has twisted their doctor's words - but her reaction seemed genuine.

At her request, I called her doctor at home. He was noticeably intoxicated on the phone, but since he was at home -- there's obviously nothing wrong with a few adult beverages. I offered to return the call for him after I noticed his state, but he unfortunately requested to do so himself. Oh, to listen to that conversation - I can't imagine any positive outcome.

I just hope Reggie is okay.

The lesson here: Before you leave your pet anywhere overnight, make sure to ask if a doctor and / or technician is in the hospital all night. Some states now require written disclosure of hours of operation and if the pet will be left unattended. If nobody is in the clinic overnight, you should be advised of a 24 hour option and or discuss the risks of leaving your pet unattended. Some stable patients (such as orthopedic surgery, declaws, etc) are truly fine left on their own. Although ER stays can be expensive, it's the cost of having doctors and staff up all night long to monitor and care for your pet. Many ill patients, such as those with seizure disorders, should NEVER be left in a clinic unattended.

Monday, March 11, 2013

It's taken me a few shifts to gather myself to be able to write this story. That's how angry I was.

Two clients arrived with their 10 year old pomeranian. The presenting complaint was difficulty breathing; it was easy to see at triage that "Syclla" was breathing too quickly and too hard. Her mucous membranes were pale, and she was definitely ill, but still able to walk and wagging her tail. My technician asked for permission for immediate emergency treatment and diagnostics, which was declined. We placed Syclla in an oxygen cage and I immediately went to talk to the family.

"Hi, I'm Erdoc, and I'm sorry to meet you at such a difficult time. What's been going on with Syclla the last few hours?" I started to ask the pertinent questions that are vitally important for a patient history and to help sort out the more likely conditions.

The husband and wife (both in their late 40s) were immediately rude. As hard as I tried to be compassionate, kind, and understanding of what is never an easy situation, they remained cool, crispy and unfriendly. Their answers were short and their attitudes impatient. Certainly I respect that different people grieve differently, so despite their attitudes, I moved on to my recommendations for their pet.

Just like any other case, I gave the clients the findings based upon my exam, and options for diagnostics (to figure out what's wrong) and possible treatment options (which would depend on what's wrong).

"Our dog is old. Don't you think this is a bit ridiculous? She's 10 for god's sake."

"I certainly agree that Syclla is older. I understand if you don't think testing or treatment is in her best interest. I meet different kinds of people all day long, and so I just want to make sure you understand the options, the risks and benefits of each option, and make a choice that's best for you and your dog. Certainly euthanasia is something we never want to go through, but is a understandable choice in this situation, and if you felt it was right, I would support your decision."

The clients asked me to leave while they talked. When I returned, they had made the final decision for euthanasia. I told them that I supported their choice 100% and I was sorry for their hard day.

The euthanasia was smooth and painless; the clients held Syclla in their arms as she passed.

After she was gone, I again expressed my sympathies for their loss. "I'm so sorry you had to say goodbye. Take as much time as you need, and whenever we can help you with anything just ----"

The husband stopped me in mid-sentence by putting his hand (open palmed) 1 inch from my face, effectively telling me to shut up and definitely the most disrespectful thing that any client has ever done to me.

It took all of my professionalism, grace and restraint to walk out of that room and shut the door without saying or doing anything I would have regretted later. I'm still angry about how much emotional energy I spent trying to be kind, caring and compassionate only to have my kindness returned with disrespect.

Tuesday, February 26, 2013

On a busy weekend in my ER, I worked efficiently through trauma patients, removed a plastic toy from a lab's intestines, repaired lacerations, and treated this and that throughout the day.

Our lobby was a hotbed of emotions. It remained packed with waiting pet owners all day; each sharing in the joys and sadness of those around them. One of the most memorable cases was a much loved 14 year old miniature poodle. The parents, a husband and wife, and their children, both younger than the dog, huddled around their pet as I listened to the history, performed a physical exam, and discussed options. Ultimately, the family decided that their beloved friend had been in failing health for too long, and euthanasia was the best answer for her. The kids had never lived without their dog; they had no memories without her yet in their life. This was clearly the first time they had experienced this type of grief, and it was truly heartbreaking. I watched as the dad comforted his family, and we all shed a few tears together. As they exited through the lobby, the entire crowd of waiting patrons was in tears.

Several hours later, after continuing with a busy shift, we were ready to discharge a patient who I had performed surgery on the day prior to remove a plastic toy he had eaten. The dog practically ran up to his clients, tail in full wag, and licked them hello. The clients had shared their story with those in the lobby who also shared the joy of a life saved and another pet going home to his loving family.

A roller coaster of emotions. Another day in the journey of an emergency veterinarian.

Thursday, January 31, 2013

Last night we received a call from a frantic pet owner. Her 4 year old dachshund was no longer able to walk. The most likely all-to-common and devastating condition was intevertebral disc disease, and is notorious amongst the breed.

She arrived, and a physical exam confirmed my suspicions.

Tearfully, the client explained to me that her dog was "her child" and she'd do anything for him. I explained to her that her dog needed a hemilaminectomy, a detailed and complex surgery near the spinal cord to relieve the problem and allow her pet to (most likely) recovery completely. The surgery is typically only performed by surgical or neurological specialists, given the difficulty of operating near the spinal cord.

Without surgery, his prognosis to walk again was significantly worse, meaning he might end up paralyzed or need a cart in the future.

"What! The surgery costs WHAT? There's no WAY I'd spend more than $300 on this dog! It's just a dog!"

Tuesday, January 1, 2013

Today I saw a young female puppy for the symptoms of bloody urine, straining to urinate, and small frequent urinations. In a female dog, these signs typically indicate lower urinary tract disease; such as a urinary tract infection, bladder stones, or other causes.

I recommended a urinalysis, a simple test to look at the urine under a microscope to look for bacteria, crystals, or cells indicating the cause. The clients and I talked about the likelihood of their puppy having a recessed vulva (a poor conformation), resulting in an easier pathway for bacteria to reach the bladder. Other possible causes included ectopic ureters, which may require surgical correction in the future. Read more about that here.

Pending test results, I recommended starting amoxicillin, the most common first line urinary tract antibiotic, as it actually is excreted in the urine, making it an exceptionally effective choice for UTIs. A typical course of therapy for an uncomplicated UTI is 7 days. (Many other reasons may indicate longer therapy).

The clients called a technician into their room.

"We looked on google, and we read that amoxicillin is a bad choice for UTIs", they said. "We want cephalexin for now, and a 30 day supply of baytril to go home just in case."

Oh GOOD! You read google for 5 minutes, so you are DEFINITELY more qualified to choose antibiotics than a doctor who spent 10 years training to do this job.

I tried to be patient and explain that cephalexin is typically a choice for skin, based upon the properties of the drug. Baytril is reserved for more serious or resistant infections, and is avoided in puppies because it may have a risk of cartilage damage in puppies under a specific age.

The clients didn't argue any more, but you could tell they weren't happy. I just CAN'T understand this mentality. Of course it's not the first time this has happened - I've had people diagnose their dogs with many, many ailments based upon google, only to find out that they've diagnosed their dog with a disease that doesn't even occur in our area. (Or similar. You get my point). Google search is an amazing tool, but is NOT even close to a substitute for medical training, testing, and experience.

All stories contained within this blog are inspired by my life as an emergency veterinarian. Details including but not limited to name, time of visit, species, and age are changed to protect the innocent and crazy alike. Any relationship to persons or animals, living or dead, is purely coincidental.

This isn't web DVM....

These stories are shared to inspire and to entertain. They are not intended to be medical advice. If your pet is sick, the only rational thing to do is have him or her seen (in real life) by a veterinarian.

Who is that masked woman, anyway?

Ever since I was little, I always had the dream of becoming a veterinarian. The dream has been realized, and my passion is emergency medicine. ER work has many pitfalls and disadvantages, but for me, the ability to be there in a moment of crisis and help both a beloved pet and their loving family, is worth the bad days.

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Definitions and commonly seen conditions

Anemia: Low PCV (see below). Anemia can result from external hemorrhage, internal hemorrhage, destruction of blood cells in the body, or inability to make new blood cells in the bone marrow.

Azotemia: Elevation in the BUN (blood urea nitrogen) or creatinine. BUN and creatinine are body wastes typically eliminated by the kidneys; increased levels in the body indicate kidney dysfunction, obstruction of urine, or severe dehydration.

Congestive Heart Failure (CHF): Accumulation of fluid in the lungs due to failure of the heart. Some symptoms include shortness of breath, decreased appetite, rapid breathing rates, coughing, and weakness.

Feline Lower Urinary Tract disease (also called feline idiopathic cystitis): A condition resulting in frequent, painful urination, and in the most severe cases, obstruction of the urethra. FLUTD has several potential causes and is also an extreme emergency.

GDV: Gastric dilatation and volvulus. Occurs in large breed dogs; the stomach fills with gas and twists. An extreme emergency, this condition is treated with stabilization and immediate surgery.

PCV: Packed cell volume. The percentage of red blood cells contained within a given sample of whole blood. Normal for dogs and cats is typically 35%-45%.